Tái Tạo Thể Tích Khuôn Mặt Bằng Filler – Kyle K. Seo (2021)

136
lateral canthus (Fig. 4.30). On occasion, an addi-
tional entry point may be created midway along
the pretarsal roll in eyes with significant
­horizontal length. The target depth of injection is
the subdermal layer, that is, between the dermis
and the orbicularis oculi m., to avoid hitting the
IMPA running deep to the orbicularis oculi m.
(Fig. 4.28). The shape of the pretarsal roll should
ideally resemble that of a banana, narrow in the
medial one-third, and slightly thicker in the lat-
eral aspect. This is achieved by depositing the HA
filler  in a retrograde manner starting  with tiny
amount of filler from near the medial canthus
immediately below the lower eyelash to run par-
allel to the lower lash line, while excercising par-
ticular care to inject with precision and constant
pressure to avoid lumpiness or an overly thick
appearance.
The pretarsal region is a soft, delicate region
not readily amenable to substantial postinjection
molding. As such, the use of HA fillers is advised
given their reversibility in case of any contingen-
cies. Also, the use of biphasic HA is preferred
over the more hydrophilic monophasic HA, to
minimize the risk of the Tyndall effect or swelling
from excessive water retention. The adequate
injection volume is 0.1–0.3 mL per side, subject to
individual variations in the desired volume.
Anesthesia consists primarily of epi-lidocaine
injection in the cannula entry points, as the use of
topical anesthetic ointment is not readily applica-
ble in the periorbital region. An infraorbital nerve
block may be considered in patients with low pain
tolerance. Alcaine® eye drop (i.e. a local anes-
thetic eye drop) can be used prior to injection in
case bleeding occurs from the rupture of the
IMPA, to numb the mucosal part of the lower eye-
lid before cotton tips are applied to control the
bleeding. Once the IMPA is ruptured by a needle
or even a cannula, it is difficult to control the
bleeding simply by compressing the site from the
outside as the structure is supported only by the
soft eyeball. In such case, compression with cot-
ton tips from both sides of the lower eyelid can
better facilitate bleeding control.  During the
advancement of the cannula, the second finger of
the non-dominant hand should be engaged to
slightly press and bend the cannula tip at the
medial one third of the pretarsal roll in order to
facilitate the movement of the straight cannula
through the convexly curved pretarsal roll. During
the injection,  the second  and third fingers of
the nondominant hand should be engaged to press
the lower border of pretarsal roll upwards in order
to
avoid
an
overly
thick
pretarsal
roll
from  the  spreading down of the  deposited HA
filler during injection.
4.5.4
Complications
Complications relating to pretarsal roll volumiza-
tion consist largely of aesthetic concerns arising
from poor placement such as lumpiness
(Fig.  4.31), sub-optimal shape, an overly thick
appearance, and other complications such as the
Tyndall effect and vascular compromise including
bruising and intravascular injection, among oth-
ers. As mentioned, rupture of the IMPA may occur
even with the use of a cannula. Failure to control
the bleeding immediately and properly in such
event may lead to severe bruising that can spread
even into the white sclera, resulting in an unsightly
bloodshot appearance for up to one month.
Therefore, timely detection of the rupture is of
essence, as is its adequate management consisting
Table 4.5  Summary of pretarsal roll augmentation injec-
tion technique
Item
Contents
Needle vs. Cannula
30-G 3-cm cannula
HA filler
Biphasic HA filler with
intermediate particle size
Amount of HA filler
0.1–0.3 mL per side
Depth of injection
Subdermal layer
Entry point for cannula
0.5 cm inferolateral to the
lateral canthus
Target area
Pretarsal roll
Anesthetics
Epi-lidocaine injection in
the cannula entry points
or an infraorbital nerve
block Application of local
eye drop with alcaine
Nondominant hand
Press and bend the cannul
tip during the advancement
of the cannula and press the
lower border of pretarsal
roll upward during injection 
4  Regional Particulars

137
Fig. 4.30  Appropriate shape of the pretarsal roll and cannula entry point for pretarsal roll augmentation
a
b
d
c
Fig. 4.31  (a) An overfilled pretarsal roll. (b) After partial reduction by hyaluronidase injection. (c) Disfiguring lumpi-
ness after pretarsal roll augmentation. (d) After partial reduction by hyaluronidase injection
4.5  Pretarsal Roll Augmentation

138
of immediate compression with cotton tips from
both sides of the lower eyelid. Considering that
the duration of pretarsal roll augmentation tends
to  extend  for more than  5  years, any  aetheti-
cally suboptimal placement of HA fillers are best
reversed and reapplied.
To completely dissolve the misplaced HA filler,
0.5–1 mL of hyaluronidase (150 U/mL) is to be
injected directly at the center of the pretarsal roll,
while partial dissolution to reduce localized thick-
ness of the pretarsal roll can be achieved by inject-
ing tiny volumes of hyaluronidase (0.1–0.2 mL) at
a diluted concentration of 30–50  U/mL slightly
inferior to the overly thickened portion.
4.6
Inferior Orbital Hollow, Tear
Trough, and Palpebromalar
Groove
Difficulty
Level:
C,
Effectiveness:
A,
Complications: C
Under-eye discoloration, colloquially referred
to as “dark circles,” is a multifactorial problem,
the four leading causes of which include ethnic
skin tones (pigmentation), visibility of the bluish
vasculature underlying the skin, skin wrinkling,
and the appearance of shadows on the skin sur-
face. Specifically, Fitzpatrick skin phototypes III
to IV are genetically more predisposed to perior-
bital hyperpigmentation, which tends to become
progressively more pronounced with age.
Congenitally robust vasculature under the eyes
or the dilation of blood vessels due to sleep
deprivation or menstruation can also induce
infraorbital darkening. Wrinkling of the infraor-
bital skin due either to aging or to chronic der-
matitis such as  atopic dermatitis or allergic
dermatitis may also cause darkening of the skin
under the eyes. The discoloration may also be
caused by congenital or progressive shadowing
under the eyes due to the hollowing of the infra-
orbital region or the herniation of the suborbital
fat (a.k.a. eye bags) or sagging of the lower eye-
lid. Of the aforementioned factors, correction of
under-eye shadows represents the simplest
and most straightforward solution to the appear-
ance of dark circles. While surgery is required
for treating lower eyebags or lower eyelid sag-
ging, volume deficit in the infraorbital area can
be addressed with HA fillers for immediate reju-
venation of the dark circles.
Infraorbital hollowness consists of three parts
depending on the location, namely the tear trough
on the medial aspect, the central infraorbital hol-
low on the central aspect, and the palpebromalar
groove on the lateral aspect (Fig. 4.32) [12]. The
tear trough is formed at the medial 1/2 of the
infraorbital hollowness, where the thin skin of
the periorbital region meets the thicker skin of
the malar region. The palpebromalar groove rep-
resents the lateral 1/2 of the infraorbital hollow-
ness resembling the indentation marks left after
wearing goggles. The central infraorbital hollow
is located outside the bounds of these two regions,
inferior to the pretarsal roll or the inferior tarsus.
The tear trough and the central infraorbital hol-
low can be a congenital feature, found commonly
in young people as well, while the palpebromalar
groove tends to be more prevalent among older
patients presenting with malar mounds and infra-
orbital fat herniation (Fig. 4.33).
Summary 1: Inferior orbital hollowness
consists of three components: the tear
trough in the medial aspect, the central
infraorbital hollow in the central aspect,
and the palpebromalar groove in the lateral
aspect.
Summary 2: For superficial volume correc-
tion, HA is injected in the subdermal layer
with a 30-G × 3-cm cannula. For deep vol-
ume correction, volume is placed in the
submuscular layer with a 27-G or 30-G ×
3-cm cannula. The use of fine biphasic HA
fillers is advised for injecting the infraor-
bital area.
Summary 3: In patients displaying hyper-
trophy of the medial band of the orbicularis
oculi m., the adjunctive use of BoNT-A is
advised at two to three spots (1.5–2 U per
spot) along the medial band. In patients
manifesting anterior malar depression, con-
current volume restoration is advised in the
anterior malar region.
4  Regional Particulars

139
4.6.1
Anatomical Considerations
The tear trough commences at the medial canthus
and extends inferolaterally along the orbital rim
to converge with the palpebromalar groove at the
midpoint of the orbital rim. A sagittal section of
the infraorbital region shows that the relevant
layers from the superficial to the deep consist of
the skin—subdermal layer—orbicularis oculi
m.—preseptal fat layer—orbital septum—infe-
rior orbital fat (Fig. 4.34) [13]. The location of
the tear trough is also consistent with that of the
orbital retaining ligament (ORL), which spans
the orbital bone and inserts into the orbicularis
oculi m. The clinical photo in Fig. 4.35 well illus-
trates the location of the  ORL represented in
white in the picture due to the vasoconstriction
induced by diffusion of the epinephrine mixed
with lidocaine injected in the cannula entry point
(Fig. 4.35). The ORL tethers the orbicularis oculi
m. down to the bone, and it is this firm attach-
ment that prevents any downward sagging of the
infraorbital fat. Instead, the infraorbital fat herni-
ates forward along the perimeter of the ORL. It
remains unclear, however, as to whether the ORL
inserts all the way up to the skin.
Meanwhile, the palpebromalar groove runs
inferomedially from the lateral canthus parallel
to the orbital rim and meets the tear trough in the
middle of the inferior orbital rim. It also lies lat-
eral to the arcus marginalis of the orbital rim.
While the palpebromalar groove can be a con-
genital condition, it is more often associated with
the aging-related protrusion of malar festoons
and lower  eye bags. The use of a cannula is
advised for injecting these periorbital regions to
avoid hitting the inferior palpebral v. and the
angular a. running in the area.
4.6.2
Pretreatment Assessment
Start by assessing the severity and the position of
the infraorbital hollowness, that is, the tear
trough, the central infraorbital hollow or the pal-
pebromalar groove. While in a vast majority of
cases depression is visible only in the tear trough
region, checks should nonetheless be made for
Central infraorbital hollow
Palpevrommalar groove
Tear trough
Fig. 4.32  Infraorbital
hollowness consists of
three parts depending on
the location, namely the
tear trough on the
medial aspect, the
central infraorbital
hollow on the central
aspect, and the
palpebromalar groove
on the lateral aspect
4.6  Inferior Orbital Hollow, Tear Trough, and Palpebromalar Groove

140
any concurrent depression(s) in the other two
areas. Checks should also be performed for the
presence of any infraorbital fat herniation or
lower eyelid sagging. Caution is required when
treating a patient presenting with lax and redun-
dant lower eyelid skin, as loose flaccid skin is not
amenable to lifting with small volume injections,
while injecting too much volume would invari-
ably lead to visible lumps. Where the patient also
presents with flattening of the anterior malar,
concurrent volume restoration is advised in the
anteromedial cheeks. One pitfall of HA filler,
especially when placed in the thin tissues of the
tear trough area, is its tendency to absorb water
from surrounding tissues and expand.  In this
respect, patients with high daily fluid intake are
more susceptible to developing posttreatment
lumpiness due to the swelling of HA. Finally, the
presence of any hypertrophy of the medial band
of the orbicularis oris m. (located immediately
below the tear trough) should be identified, as its
contraction during smiling may cause the HA
filler placed in the tear trough to clump up and
protrude anteriorly (Fig. 1.12).
4.6.3
Injection Technique (Table 4.6)
The use of biphasic HA fillers with small particle
size is preferred for injecting the delicate infraor-
bital  area. Monophasic HA fillers are not
­recommended since they are more prone to absorb
water and swell. The use of a thin 30-G × 3-cm
cannula is generally preferred for treating the deli-
a
b
c
d
Fig. 4.33  (a) Before and (b) after tear trough volumization in a 28-year-old female. (c) Before and (d) after volumiza-
tion of the tear trough, palpebromalar groove, and anterior malar depression in a 48-year-old female
4  Regional Particulars

141
cate infraorbital area, while the larger 27-G × 3-cm
cannula can also be used for performing deep
injections. There is a vast network of small vessels
underlying the periorbital area, and even a can-
nula may be capable of  damaging any of the
weakened vascular walls, causing extensive bruis-
ing, particularly when a thin 30-G microcannula
is employed. The cannula entry point is created
inferior orbital fat
tarsal plate
inferior medial palpebral a.
orbital septum
orbicularis retaining ligament
orbicularis oculi m.
suborbicularis oculi fat (SOOF)
Levator labii superioris m.
Fig. 4.34  A sagittal
section of the
infraorbital region
Table 4.6  Summary of infraorbital hollow injection
technique
Item
Contents
Needle vs.
Cannula
30-G 3-cm cannula for the subdermal
layer
27-G or 30-G 3-cm cannula for the
deep submuscular layer (preseptal
layer)
HA filler
Biphasic filler with fine particles
Amount of
HA filler
0.1–0.3 mL per side for the tear
trough
0.1–0.5 mL per side for the central
inferior orbital hollow
0.3–0.6 mL per side for
the palpebromalar groove
Depth of
injection
Subdermal layer for superficial
correction
Submuscular layer for deep injection
Entry point
for cannula
0.5–1 cm from the end of the tear
trough for the tear trough
1 cm inferolateral to the lateral
canthus for the central inferior orbital
hollow
1 cm lateral to the lateral canthus for
the palpebromalar groove
Target area
Tear trough
Central inferior orbital hollow/
palpebromalar groove
Anesthetics
Topical anesthetics
Nondominant
hand
Hold the skin in opposite direction to
the cannula advancement in order to
maintain the skin tension
Fig. 4.35  This clinical photo well illustrates the circum-
ference location of the orbital retaining ligament repre-
sented in white due to the vasoconstriction induced by
diffusion of the epinephrine mixed with lidocaine injected
in the cannula entry point
4.6  Inferior Orbital Hollow, Tear Trough, and Palpebromalar Groove

142
with a 26-G needle. To minimize bruising and
avoid damage to the extensive vasculature con-
tained in the periorbital region, it is important to
insert the needle slowly with the bevel facing
downwards. In the event of any vascular damage,
firm compression should be applied to the area for
at least 3 mins to stop the bleeding.
4.6.3.1 Tear Trough
The relevant depth of injection is determined by
the severity of the tear trough. For mild tear
troughs, corrections are made in the subdermal
layer superficial to the orbicularis oris m. with a
30-G cannula. For deep tear trough deformities,
use of the  double-layering technique helps to
avoid Tyndalling caused by placing too much HA
filler superficially in the subdermal layer. Here,
HA filler is placed deep to the orbicularis oris m.
into the preseptal fat layer using a 27-G × 3-cm
cannula, before detailed refinements are made
subdermally using a 30-G  ×  3-cm cannula
(Fig.  4.36). The cannula entry point is made
0.5–1 cm away from the end of the tear trough
along a straight line extending from the same
(Fig.  4.36). Where the tear trough continues
beyond the medial one-third of the infraorbital
hollow into the area under the pupil, running hor-
izontally parallel to the orbital rim, a second lat-
eral insertion point is required to address this
horizontal portion of the tear trough (Fig. 4.37).
Concerning the injection volume, 0.1–0.3 mL of
HA in the subdermal level and 0.1–0.3 mL of HA
in the preseptal fat layer provide sufficient cor-
rection. The thin skin of the tear trough area is apt
to reveal any undesired expansion of HA filler
from excess water absorption. Thus, the goal
should be a slight under-correction rather than
attempting full correction in a single session. The
use of topical anesthetic cream is sufficient for
local numbing. Note, however, that numbing
cream applied for a prolonged duration can cause
the skin to swell and obscure the appearance of
the tear trough to be corrected. As such, the cream
should be applied only at the cannula insertion
point rather than across the entire treatment area.
4.6.3.2 Central Inferior Orbital Hollow
The central infraorbital hollow refers to the
under-eye hollowness located below the pretarsal
roll or the inferior tarsus. Here, a 27-G × 3-cm
cannula is first inserted into the preseptal fat to
substantially fill the depression from the inferior
tarsus to the tear trough, before fine-tuning the
result with a 30-G cannula maneuvered subder-
mally. The cannula insertion point is made 1 cm
lateral and 1  cm inferior to the lateral canthus
(Fig. 4.37). Small volume injection of 0.1–0.5 mL
is advised per side, depending on the severity of
the depression.
4.6.3.3 Palpebromalar Groove
Using
the
double-layering
approach,
a
27-G  ×  3-cm cannula is introduced first at the
supraperiosteal layer deep to the orbicularis oris
Skin
Subcutaneous fat layer
Orbicularis oculi m.
HA filler
SOOF(suborbicularis oculi fat)
Periostium
a
b
Fig. 4.36  (a) Depth of injection for the tear trough, (b) sonographic findings of HA filler injected into the tear trough
4  Regional Particulars

143
m. for the primary volumization, before a 30-G
cannula is used for making detailed corrections at
the subdermal layer (Fig.  4.37). The cannula
entry point is made 1 cm lateral to the lateral can-
thus (Fig. 4.37). The amount of HA filler injected
is 0.3–0.7 mL is per side, though a larger volume
may be required to fill the deep palpebromalar
grooves caused by severe herniation of fat pads
with advancing age.
4.6.3.4 Combination Treatment
In patients presenting with a hypertrophic medial
band of the orbicularis oculi m. under the eyes,
the adjunctive use of BoNT-A in two  to three
points along the band (1.5–2 U per spot) can fur-
ther optimize results (Fig. 4.38). Where the patient
presents with concurrent depressions in the ante-
rior malar region, make sure to restore also the
volume deficit in the anteromedial malar to
smoothen the transition at the lid–cheek junction.
4.6.4
Complications
Irregularities: The thin unforgiving skin of the
periorbital area makes the region particularly sus-
ceptible to contour irregularities. Even a slight
overfilling or swelling of the injected HA filler
may cause disfiguring lumpiness  in the area
(Fig. 4.39). The risk is higher with monophasic
HA fillers, which are more hydrophilic in nature
than biphasic fillers (Fig. 2.23).
Bruising: To prevent damage to the rich vascu-
lature underlying the area while puncturing the
cannula entry point insert a 26-G needle slowly
with the bevel facing downwards, taking care to
avoid visible veins.
Tyndall effect: As is the case with irregulari-
ties, the thin skin of the periorbital area also
makes this region particularly susceptible to the
Tyndall effect. Avoid placing too much HA filler
superficially in the subdermal layer.
a
c
d
b
Fig. 4.37  The cannula entry point for (a) tear trough (b) central infraorbital hollow (c) palpebromalar groove, and (d)
total infraorbital hollow
4.6  Inferior Orbital Hollow, Tear Trough, and Palpebromalar Groove

144
4.7
Nasojugal Groove
Difficulty
Level:
A,
Effectiveness:
A,
Complications: B
c
1.5 - 2U
a
b
Fig. 4.38  Use of botulinum toxin to treat the hypertrophic medial band of the orbicularis oris m. (a) Before, (b) after
and (c). Injection points for the hypertrophic medial band of the orbicularis oris m
a
b
Fig. 4.39  (a) Before and (b) after tear trough volumization. Note the appearance of lumpiness in the treated area
Summary 1: A23-G × 5-cm cannula is used
for deep injections into the SOOF.  Both
biphasic HA fillers with large particle size
and monophasic HA fillers with high visco-
elasticity are acceptable for use.
Summary 2: The adjunctive use of BoNT-A
can optimize results in patients presenting
with a hypertrophic medial band of the
orbicularis oculi m. under the eyes.
Injection of BoNT-A is advised at two spots
(1.5–2 U per spot) along the medial band.
In patients manifesting concurrent depres-
sion in the tear trough, volume replacement
should be performed in the tear trough in
conjunction with the nasojugal groove.
4  Regional Particulars

145
Flattening of the anteromedial malar can exac-
erbate the appearance of under-eye dark circles
and create the perception of facial descent by dis-
rupting  the smooth convexity of the face with
intervening concavities (Fig. 4.40). Furthermore,
the loss of volume in the anteromedial malar
region combined with the persistence of fullness
in the nasolabial component of the malar fat pad
contributes to the formation of a conspicu-
ous  groove commencing at the tear trough and
running obliquely from superomedial to inferolat-
eral across the medial malar, often intruding into
the submalar depressions or cheek hollows below.
This groove is referred to interchangeably as
the nasojugal groove, the mid-cheek groove, or
the mid-cheek furrow, though “mid-cheek
groove” is a broader term that extends to also
cover submalar depressions. Nasojugal grooves
are also commonly known as Indian bands, as
they resemble the painted stripes on the faces of
Native American Indians [12]. Tear troughs may
sometimes be considered to form part of the
nasojugal groove [14] (Fig. 4.41).
Nasojugal grooves can occur due to multiple
causative factors, including a congenitally strong
fixation of the zygomatic cutaneous retaining
ligament (ZCRL), a congenitally weak and
underdeveloped maxillary bone, depletion of
malar fat volume due to aging or weight loss,
hypertrophy of the nasolabial fat  with aging,
among others. While nasojugal grooves may also
be present in young patients with a  congenital
maxillary deficiency or with an inherently promi-
nent zygomatic cutaneous retaining ligament, in
a large majority of cases, the groove becomes
more identifiable with advancing age or weight
loss, due to the resulting deflation and descent of
the malar fat pad. The malar fat pad is separated
by the retaining ligament into the lower compart-
ment (nasolabial fat) which progressively slides
down and inwards with age toward the nasolabial
folds, and the upper compartment (malar fat)
which remains suspended in place by the strong
ligamentous fixation provided by the zygomatic
ligament. Conversely, the hypertrophy of the
malar fat pad with aging may cause the fat pad to
bulge as two discrete entities, separated by the
ZCRL into the malar mound (malar bag) above
and the nasolabial fat sitting below. The relative
prominence of these structures, in turn, can
also  accentuate the depth of the nasojugal
groove lying in between.
4.7.1
Anatomical Considerations
From the outer to inner, the anteromalar region
consists of the following layers: the skin—subcu-
taneous fat layer/superficial layer of malar fat
pad—orbicularis oculi m—SOOF, suborbicularis
oculi fat layer/deep layer of malar fat pad—
expression muscle layer including the levator
labii superioris and zygomaticus minor—infraor-
bital nerve—periosteum (Fig.  4.42). The malar
fat pad is divided by the orbicularis oculi m into
the superficial subcutaneous and the deep SOOF
layers and separated by the ZCRL into the supe-
rior and inferior compartments. The ZCRL runs
from superomedial to inferolateral across the
medial malar, and it is on the basis of this struc-
ture that the malar fat pad is segmented into the
malar mound superiorly and the nasolabial  fat
inferiorly (Fig. 4.43) [14]. Nasolabial fat progres-
sively slides down and inwards with age toward
the nasolabial folds and the upper compartment
(malar fat) remains suspended in place by due to
the strong ligamentous fixation provided by the
ZCRL. In 30% of Asians, a detoured branch of
the facial artery courses in front of the anterome-
dial malar region along the medial band of orbi-
cularis oculi m. at the level of SOOF before
branching
into
the
angular
artery
[15].
Summary 3: In patients concurrently exhib-
iting sunken cheeks or prominent lateral
zygoma, volume should be placed concom-
itantly in the respective hollows of the
cheek to ensure overall facial balance and
proportionality.
Summary 4: The combined use of steroid-
based fat-dissolving injections can produce
more favorable outcomes in patients with a
pronounced malar fat pad.
4.7  Nasojugal Groove

146
a
b
c
d
Fig. 4.40  (a, c) Before and (b, d) after volumization of the nasojugal groove combined with volumization of the
sunken cheeks
4  Regional Particulars

147
Tear trough
Infraobital fat
=eyebag
Malar mound
= Malar bag
Nasojugal groove
= Indian band
= Midcheek groove
Nasolabial fat
Palpebromalar groove
Fig. 4.41  Location of
the nasojugal groove and
tear trough
orbicularis retaining ligament
orbicularis oculi m.
suborbicularis oculi fat (SOOF)
Levator labii superioris m.
zygomatic retaining ligament
Fig. 4.42  A sagittal
section of the
anteromalar region
4.7  Nasojugal Groove

148
Accordingly, the use of a cannula is preferred
over a needle for injecting this area in Asian
patients.
4.7.2
Pretreatment Assessment
Gender differences should be borne  in mind
when volumizing the nasojugal groove with fill-
ers in order not to feminize male subjects. In such
context, injection of discreet amounts is advised
in male  subjects, as a slightly rugged chiseled
cheek contour is favorably associated with male
charisma. On the contrary, more volume in the
malar area would be acceptable for female sub-
jects. In subjects  with a prominent zygomatic
arch, adding extra volume in the malar area, even
when placed medially in the anteromedial aspect,
may cause the entire zygoma to look wider as a
whole. Since prominent zygoma is disfavored by
Asians, it may be preferable to inject only mini-
mal amounts, if not omit the treatment altogether,
in subjects displaying prominent zygoma.
Alternatively, concurrent filling of the subma-
lar hollows in such subjects can help diminish the
appearance of prominent zygoma (Fig.  4.44).
Fig. 4.43  Diagram of
the superficial facial fat
compartment. The malar
fat pad is divided by the
zygomatic cutaneous
retaining ligament into
the superior (malar fat,
malar mound) and
inferior (nasolabial fat)
compartments
4  Regional Particulars

149
a
b
c
d
Fig. 4.44  Concurrent flling of the submalar hollows can help diminish the appearance of prominent zygoma caused by
the volumization of the nasojugal groove (a, c) Before and (b, d) after
4.7  Nasojugal Groove

150
a
b
Fig. 4.45  Malar dimples can be improved by the injection of botulinum toxin (1.5U) combined with the injection of
botulinum toxin on the medial band of the orbicularis oris m. (a) before (b) after
Meanwhile, augmenting only the anteromedial
malar in patients with concurrent depressions in
the tear trough and palpebromalar groove may
accentuate the relative prominence of the infraor-
bital hollows. Accordingly, it is advisable to
address the volume deficit in these adjacent areas
in tandem to give the face a more balanced
appearance.
It is also important to identify the presence,
if any, of a hypertrophic medial band of the
orbicularis oris m. immediately below the tear
trough (Fig. 4.38). The contraction of this band
upon smiling may cause the HA filler injected
in the anterior malar to bunch together and
bulge forward whenever the patient smiles.
With repeated contraction, the aggregated HA
filler may settle as a conspicuous lump visible
even at rest. Adjunctive injection of BoNT-A is
advised in such patients to prevent such appear-
ance of lumpiness. In rare cases, the orbicularis
oculi may insert into the  ZCRL in the mid-
cheek, resulting in the formation of dimples on
smiling (Fig. 4.45). The injected HA filler, in
such case, tends to show a reduced duration of
effect.
Where the nasojugal groove has become more
conspicuous due to the relative protrusion of the
malar fat (malar mound), it is preferable to first
reduce the excess volume in the malar fat via sub-
cutaneous steroid injections or facial liposuction
before augmenting the volume deficiency in the
nasojugal groove (Fig. 4.41).
4.7.3
Injection Technique (Table 4.7)
Both biphasic HA fillers with large particle size
and monophasic HA fillers with high viscoelas-
ticity are acceptable for use in the anterior malar
area. The used of a 23-G  ×  5-cm cannula is
preferred, while a finer 25-G or 27-G cannula
can also be used for layering the HA filler
additionally  at the superficial subcutaneous
level. The depth of injection is the deep SOOF
layer deep to the orbicularis oculi (Fig.  4.46).
Care should be taken not to inject too deep and
hit the levator labii superioris m. lying below the
SOOF since it can cause significant pain to the
patient. For permanently etched in Indian bands,
treatment should also include superficial injec-
tion in the superficial subcutaneous fat layer in a
double-­layering technique.
The cannula entry point is created along the
extension of the nasojugal groove, 1  cm away
from where  groove ends, at the intersection
between a vertical line 1 cm lateral from the lat-
4  Regional Particulars

151
eral canthus and a horizontal line running through
the nasal base (Fig.  4.47). Insert the cannula
deeply into the SOOF layer and inject HA filler
using the retrograde linear thread technique along
the length of the groove into its deepest central
portion for primary volumization. Next, repeat-
ing the same process, make parallel retrograde
linear  injections  immediately above and below
the first injection to level out the groove shaped
in the form of a half-cylinder to yield an even
contour. Concerning the injection volume,
0.5–2 mL of HA filler is typically delivered per
side  depending on the severity of depression,
though over 3 mL may be required per side in
patients with maxillary deficiency. For anesthe-
sia, the application of topical numbing cream
should suffice. The nondominant hand should be
used to stretch the skin taut both inferiorly and
laterally during the injection to tighten the cheek
area to facilitate cannula advancement.
Table 4.7  Summary of nasojugal groove augmentation
technique
Item
Contents
Needle vs. Cannula
23-G 5-cm cannula for SOOF
layer, 25-G or 27-G 5-cm
cannula for the superficial
subcutaneous fat layer
HA filler
Biphasic HA filer with large
particle size or monophasic
HA filler with high
viscoelasticity
Amount of HA filler
0.5–2 mL per side
Depth of injection
Deep SOOF layer above the
muscle layer
Superficial subcutaneous layer
if necessary
Entry point for
cannula
1 cm from the end of the
nasojugal groove along the
extension of the same
Target area
Mid cheek groove
Anesthetics
Topical anesthetics
Nondominant hand
Hold the skin tightly in the
posterior direction to maintain
skin tension
Fig. 4.46  Depth of
injection for the
nasojugal groove
volumization
4.7  Nasojugal Groove

152
Fig. 4.47  The cannula entry point for the nasojugal groove volumization
Tip: Corticosteroid Fat-Reducing
Injections
A nonsurgical injectable  solution promis-
ing to melt away unwanted fat can be noth-
ing short of a miracle. A slew of different
concoctions has been introduced to this end
so far, including injectables that purport to
stimulate the neurotransmitters of the sym-
pathetic nervous system to break down
localized fat deposits, hypotonic solutions
mixed with distilled water which claim to
encourage fat dissolution, and hyaluroni-
dase injections for dissolving the hyal-
uronic acid present in the intercellular
substance of the fat tissues. However, the
results of these treatments have turned out
to be mostly underwhelming. The two non-
surgical treatments tried and tested in their
ability to reduce fat are deoxycholic acid
and corticosteroid injections, each with its
associated drawbacks.
Kybella® (Allergan,  USA), containing
deoxycholic acid as the active ingredient,
represents the first US FDA-approved
injectable treatment for addressing the
“double chin” or the submental fat present
below the chin. However, the results of
Kybella® cannot be achieved in a single
session, requiring up to 3–6 treatment ses-
4.7.3.1 Combination Treatment
In patients presenting with a hypertrophic medial
band of the orbicularis oculi m. under the eyes,
the adjunctive use of BoNT-A in two  to three
points along the band (1.5–2 U per spot) can help
to  optimize results. Adjunctive injection of
BoNT-A at malar dimples is also advised in
patients with malar dimples (Fig. 4.45). Where
the patient presents with a concurrent tear trough
deformity, palpebromalar groove, or submalar
depression, volume in these regions should pref-
erably be restored in tandem in order to give the
face a more balanced appearance. The combined
use of steroid-based fat-reducing injections (dis-
pensed over 2–3 sessions) is advised in patients
with substantial fullness in the malar fat pad.
4  Regional Particulars

153
sions spaced 1 month apart, each accompa-
nied by significant swelling and tenderness.
The appeal of a nonsurgical solution can be
outweighed by the substantial downtime
involved due to the swelling and pain fol-
lowing each treatment session. In this
respect, a facial liposculpture, as a one-time
procedure, arguably represent a more effi-
cient option.
Meanwhile, steroid-based fat-reducing
injections induce fat reduction by leverag-
ing one of the common side effects of corti-
costeroids, fat atrophy, for cosmetic
purposes. Swelling usually resolves within
2 hrs of injection while bruising can largely
be avoided with the use of a cannula.
However, given their nature as steroid hor-
mones that are capable of causing systemic
side effects including disrupted menstrual
cycle, moon face syndrome, and acne, limi-
tations apply in terms of the maximum dose
per session, interval between treatments,
and the number of consecutive treatments
that can be undertaken. Caution must be
taken, as these steroids may cause atrophy
not only in the subcutaneous fat but also in
the dermis when used in high concentra-
tions or doses, leading to dermal thinning
and atrophic indentations on the skin sur-
face (Fig. 4.48).
Note that in areas of excess facial fat,
when the HA filler is injected to fill the hol-
lows in an adjacent area, the injected vol-
ume may serve to exaggerate the existing
fullness as it pushes against the surround-
ing tissues. By way of example, HA filler
placed in the buccal hollows or the nasola-
bial folds may exacerbate the appearance of
sagging jowls, while the volume added in
the nasojugal grooves may aggravate the
bulge of the malar mounds or the malar fat
pad sitting above the nasolabial fold.
In such cases, the combined use of ste-
roid-based fat-reducing injections can help
achieve a smoother  and more natural
appearance. Steroid based fat-reducing
injections can be safely administered based
on the following guidelines. The use of a
cannula can  help to avoid bruising. Deep
injection into the subcutaneous layer helps
to prevent dermal atrophy. In the case of
dexamethasone injections, 1–2  mL is
injected per spot at a concentration of 1.25
mg/mL to a maximum of 8 mL per session.
Dexamethasone can be dispensed in up to
three consecutive sessions spaced 1  week
apart, though, given its short half-life of 3 h,
the interval may be shortened to 3 days.
In comparison, triamcinolone has a lon-
ger half-­life; 1–2 mL is injected per spot at a
concentration of 5 mg/mL to a maximum of
8 mL per session. It can be dispensed in up
to three consecutive sessions spaced 2 weeks
apart. While triamcinolone is more effica-
cious than dexamethasone, it is more prone
to the risks of dermal atrophy and systemic
complications. For this reason, dexametha-
sone is the preferred choice of steroid injec-
tions for inducing fat reduction.
Fig. 4.48  Dermal atrophy caused by fat reducing injection
4.7  Nasojugal Groove

154
4.7.4
Complications
Irregularity: Volume restored in the medial malar
needs to be proportionate to the rest of the face.
Augmenting the mid cheeks alone without con-
sidering the transitions to the adjacent areas or
the hollowness in the tear trough above can results
in unnaturally abrupt transitions in the facial con-
tour. Meanwhile, repeated contraction of a hyper-
trophic medial band of the orbicularis oris m.
may lead to the subsequent migration and bunch-
ing of the HA filler. Further, discrepancy in the
HA filler duration in different facial regions may
create an obvious “step” in the lid–cheek junction
6–12  months following treatment as the
­volume  deeply placed in the anterior malar
area  dissipates more quickly  while the superfi-
cially implanted volume in the tear trough
remains intact (see Sect. 5.2).
Episode: Sure, We Hire Based on Looks
Patients occasionally ask if I happen to
hire my staff based on their looks, as a
well-meant joke to compliment my
immaculately presented staff. Each time, I
respond with a ready comeback “Of
course. In fact, that’s our sole criteria” to
which both the patient and the staff burst
out laughing. Needless to say, comments
like this, in this day and age, can border on
workplace sexual harassment, but I am
pleased to report that so far, no such com-
plaints have been raised by any of my
staff. Notably, one critical element of a
sexual harassment claim is the subjective
feeling of the aggrieved employee, that is,
how the individual felt after what was said
or done. Accordingly, a casual offhand
joke can constitute harassment if the vic-
tim took offense  from it. Conversely, to
the extent that the comment was not con-
sidered as an insult by the employee, then
there is no case for a  harassment  claim.
Needless to say, my responses have so far
been  taken by my staff as nothing more
than a witty compliment.
As aptly noted in the book Whale Done!,
everybody appreciates a good compliment,
and that includes doctors too. After per-
forming filler treatments, I make it a rule to
pass a mirror to the patient to obtain their
immediate assessment and feedback. While
invariably, the results are instantaneous and
changes visible, the response from patients
are varied and diverse. Some would stick
both thumbs up in delight and exclaim “No
wonder you are the Master of Fillers!”
Others stare intently into the mirror scruti-
nizing their faces for any odd asymmetry or
imperfection. Granted, Koreans are not best
known for their expressiveness and can be
rather tight with compliments. The major-
ity of my patients are therefore either non-
responsive if not fall into the latter
category  of tough critics. So in the occa-
sional event I get a patient who happens to
be generous with compliments, that can
really make my day.
Upon obtaining my medical license I had
originally set out to become a professor at a
university hospital where, hopefully, I could
engage in both research and patient consul-
tation. Things did not exactly work out
according to plan and in the end I ended up
starting my private practice. My biggest
qualm regarding that decision was whether I
could draw the same sense of purpose and
fulfillment as a physician when most of my
daily practice would revolve around per-
forming aesthetic procedures  for clients
rather than getting down to the serious busi-
ness of treating diseases for patients. This
coming from a dermatologist may come
across as a frivolous concern compared with
the work of  general surgeons or cardiolo-
gists whose entire practice is built around
dealing with matters of life and death. To my
relief, however, such concerns became a
moot point within a few years of opening
my own clinic. Soon enough I was receiving
positive feedback from clients  genu-
inely  pleased with their rejuvenated and
4  Regional Particulars

155
refined appearances, which I found to be just
as gratifying and rewarding as those received
from patients treated for their illness.
“Getting the procedure was the best
decision I’ve made this year.”
“It’s as if somebody’s turned the clock
back by 10 years”
“Magical!”
“Absolutely addictive”
Truth be told, I have a sweet spot for
short yet captivating plaudits  like these.
Sometimes I would go the extra mile sim-
ply for the joy of eliciting more such
response by adding extra doses or address-
ing facial areas that extend beyond the orig-
inal treatment plan at no extra charge.
Apparently, positive feedback from patients
is what motivates me to go to these lengths
to achieve the best possible result.
In Whale Done!: The Power of Positive
Relationships MIT professor and top busi-
ness consultant Ken Blenchard describes
how animal trainers pay positive attention
to killer whales rather than punishing their
unwanted negative behavior to encourage
these massive unwieldy creatures, weigh-
ing more than three tons, to leap several
meters above water as per the trainer’s
instructions. This approach is also is backed
up by the famous study by Robert
Rosenthal, Professor of Psychology at the
Harvard, where students at an elementary
school were given a disguised IQ test,
of  which 20% (selected at random) were
represented to the teachers as having a par-
ticularly higher IQ. Interestingly, students
who were described as having higher IQs
actually showed significant gains in both
their IQ score and exam results in subse-
quent tests taken 8  months later. Dubbed
the Rosenthal effect, this establishes how
positive expectation and attention on the
part of the teacher can positively affect the
performance of the student by encouraging
the  students to live up to teacher
expectations.
Humans, like all other animals, are
social learners. We learn to perform behav-
iors in such a way to gain reward and to
avoid sanctions. In retrospect, I realize my
entire life too has been shaped by my
endeavors to win the approval and praise of
my parents as a child, my teachers as a stu-
dent, my professors as a medical resident,
and my patients for the past 20  years as
their aesthetic physician. Positive feedback
is in my mind is the most powerful driver
for boosting higher performance. So the
next time you feel inclined to applaud
someone on their strengths, don’t be shy.
After all, there’s nothing like a good com-
pliment to bring out the best in all of us
(September 2019).
4.8
Malar Eminence
Difficulty
Level:
A,
Effectiveness:
A,
Complications: B
Summary 1: A 23-G × 5-cm cannula is used
for injection in the supraperiosteal layer
deep to the SOOF. Both biphasic HA fillers
with large particle size and monophasic HA
fillers with high viscoelasticity are accept-
able for use.
Summary 3: Augmentation of the zygo-
matic arch is not suited for northern facial
type Asians with an inherently pronounced
zygoma, as accentuating the zygomatic
prominence serves to broaden their wide
faces.
Summary 2: Volume is enhanced in the
zygomatic arch lying lateral to a line con-
necting the lateral canthus and the oral
commissure.
4.8  Malar Eminence

156
Enhancement of the malar eminence can com-
plement a thin dolichocephalic Caucasian face by
creating definition and adding balance to the hor-
izontally narrow facial appearance [16].
And also a slight convexity of the lateral
zygoma is a feature highly coveted by Caucasian
females, as it forms an integral element of the
“Ogee (Ω) curve” or the “triangle of beauty”
upheld as the aesthetic ideal in this population
[17] (Fig. 4.13).
4.8.1
Anatomical Considerations
From the outer to inner, the relevant tissue layers
of the lateral cheek can be divided as follows: the
skin—subcutaneous fat layer or the superficial
layer of the malar fat pad—orbicularis oculi m.—
SOOF or the deep layer of the malar fat pad—
mimetic muscles including the zygomaticus
minor and major—periosteum (Fig. 4.49).
4.8.2
Pretreatment Assessment
Malar eminence augmentation is a prime exam-
ple where ethnic differences must be considered
when performing filler injection (see Sect. 1.3).
Accentuating the zygomatic arch works best for a
Caucasian female subject presenting with a long,
narrow dolichocephalic face, as it brings the mid-
face closer to achieving the aesthetic ideal of the
Ogee curve. By contrast, the procedure is not rec-
ommended for a northern facial type Asian dem-
Fig. 4.49  Depth of
injection for the malar
eminence
4  Regional Particulars

157
cally costs around $1500, the equivalent of
what it costs to get a GI endoscopy alone in
the United States. In this respect, getting a
medical package in Korea makes better eco-
nomic sense for overseas Koreans even con-
sidering the cost of the round trip airfare.
Aesthetic procedures represent another
must-­do in Korea as treatments performed
by Western physicians tend to miss the
subtle nuances of the aesthetic ideal pur-
sued by Koreans. Even in the most skilled
and capable hands, Asian patients tend to
find aesthetic outcomes produced by their
Western-trained doctors less than satisfac-
tory due to the differences in beauty stan-
dards to which they aspire. This typically
occurs in the context of Asian double-eye-
lid surgeries or augmentation rhinoplasty
performed overseas. The purpose of the
double-eyelid surgery is to create a pretar-
sal crease (i.e., “double eyelid”)  in an
upper eyelid that is naturally without a
Episode: A must-do in Korea
It has long been the case that two of the top
things to do when a Korean female residing
in the U.S. visits Korea are getting a medi-
cal check-up and undergoing an aesthetic
procedure. Health screening programs in
Korea are efficient, of good quality, and
affordably priced. A comprehensive medi-
cal screening program inclusive of both
upper GI endoscopy and colonoscopy typi-
onstrating a brachycephalic face, as highlighting
the zygomatic prominence would only serve to
make their broad  zygoma appear bigger and
wider [18] (Fig. 4.50). That being said, a slight
elevation of the malar eminence may be of
benefit to a southern facial type Asian patient
­manifesting a small narrow face (Fig.1.16). It is
therefore  prudent  to consult with each patient
regarding their individual aesthetic preferences
before proceeding with the augmentation of the
malar eminence. 
Western Style
0.7 ml HA filler
Asian Style
0.8 ml HA filler
Fig. 4.50  Differences
in malar augmentation
between West and East.
Accentuating the
zygomatic arch is not
recommended for a
Northern Facial Type
Asian demonstrating a
brachycephalic face, as
highlighting the
zygomatic prominence
would only serve to
make their broad faces
appear bigger and wider
4.8  Malar Eminence

158
filler is indicated for a Caucasian patient,
volume is typically added laterally in the
malar eminence and zygomatic arch to
accentuate the triangle of beauty or the
Ogee (Ω) curve upheld as the aesthetic
ideal in this population. However, a prom-
inent lateral zygoma set against sunken
cheeks is a feature largely disfavored by
an average Korean female whose percep-
tion of facial beauty consists of an oval
babyish face with full plump cheeks.
Where the physician and patient are not
on the same page in terms of their facial
aesthetic standards and preferences, the
well-meaning Western physician may
believe he provided satisfactory augmen-
tation of the patient’s lateral cheeks, while
the Korean patient is left displeased with
the wider zygoma she ended up with.
Obviously, this is what causes the over-
seas Korean resident to seek out HA filler
treatments in Korea where she can find a
practitioner whose aesthetic style reso-
nates with her better. Fortunately, it is a
welcome development that a growing pro-
portion of Western physicians practicing
in the United States and elsewhere are
becoming increasingly appreciative of the
ethnic variations in aesthetic standards
and are differentiating their HA filler and
BoNT-A treatments  to ethnic patients
accordingly.
pretarsal crease. However, double-eyelid
surgeries performed by Western-trained
plastic surgeons tend to create lid creases
too tall for the narrow Asian eyes.
Meanwhile, rhinoplasty undertaken in
Caucasians is known to be geared primar-
ily toward reduction rhinoplasty indicated
for decreasing a humped or an overly large
nose in contrast to augmentation rhino-
plasty highly requested by Asian patients
to elevate their flat noses.
The same can be said of BoNT-A treat-
ments. Whereas smaller doses of BoNT-A
are more appropriate for Asians given the
relatively reduced activity and mass of their
facial mimetic muscles, the use of high
BoNT-A dosages typically described for
Caucasians  tends to result in an unnatural
frozen appearance in Asian patients. Also,
while the preferred shape of eyebrows for a
Korean woman is horizontally straight and
flat, failure to appreciate such aesthetic pref-
erences on the part of the Western practitio-
ner will lead to highly arched brows that are
disfavored by Koreans as it gives their faces
a harsh and severe appearance. Whereas a
Caucasian physician may favor effacing the
under-eye pretarsal fullness in Asians with
BoNT-A believing it to cause the relatively
small palpebral aperture in Asians to appear
even smaller upon smiling, a Korean aes-
thetic patient would instead elect to have
their pretarsal roll augmented with HA fill-
ers, as the presence of this roll imparts a soft,
friendly, and smiley impression. In a nut-
shell, mapping the BoNT-A treatment strate-
gies and dosages described for Caucasians
directly onto an Asian patient can create a
face that appears aggressive and unnatural,
devoid of any feelings or expressions.
The same applies to filler treatments.
Taking the popular treatment of cheek
augmentation as an example, when cheek
4.8.3
Injection Technique
Both biphasic HA fillers with large particle size
and monophasic HA fillers with high viscoelas-
ticity are acceptable for use (Table 4.8). The use
of a 23-G × 5-cm cannula is generally preferred
for treating the lateral cheeks. The relevant plane
of injection is the supraperisoteal layer at the
deepest level of the SOOF below the orbicularis
4  Regional Particulars

159
oculi (Fig. 4.49). The cannula entry point is made
at the intersection between a vertical line
dropped from the lateral canthus and a horizontal
line running through the nasal base (Fig. 4.51).
Insert the cannula deep into the SOOF of the
zygomatic arch and place the filler  along
the  zygomatic arch from the midpoint of the
arch to the point sitting lateral to the line connect-
ing the lateral canthus and the oral commis-
sure. Augment the zygomatic arch to the desired
height by depositing  HA via  retrograde linear
threading for primary volumization. Next, using
the same approach, place smaller amounts of HA
immediately above and below the first injec-
tion to smoothen the curvature of the malar emi-
nence. The injection volume should range
between 0.5 and 2 mL, depending on the defi-
ciency of lateral cheek volume. The nondominant
hand should be used to stretch the cheek infero-
medially during the procedure to maintain ten-
sion on the skin overlying the lateral zygoma.
Concerning anesthesia, application of topical
numbing cream should suffice. Where the patient
presents with concurrent  depression in the
anteromedial malar or a palpebromalar groove,
volume should be added concurrently in these
adjacent regions for a more favorable aesthetic
balance.
Table 4.8  Summary of injection technique for lateral
cheek augmentation
Item
Contents
Needle vs.
Cannula
23-G 5-cm cannula for SOOF layer
HA filler
Biphasic HA filer with large
particle size or monophasic HA
filler with high viscoelasticity
Amount of HA
filler
0.5–2 mL per side
Depth of
injection
Deep SOOF layer above the
periosteum
Entry point
for cannula
The point where a vertical line
from lateral canthus meets the
horizontal line from the nasal base
Target area
Zygomatic arch from the midpoint
of the arch to the point
sitting lateral to the line connecting
mouth corner and the lateral
canthus
Anesthetics
Topical anesthetics
Nondominant
hand
Hold the skin inferiorly in order to
maintain the skin tension
Fig. 4.51 
Cannula entry point for
malar eminence
augmentation
4.8  Malar Eminence

160
4.8.4
Complications
Irregularities: Augmenting the lateral cheeks
without regard to the concurrent anteromedial
malar depression, submalar depression or a pal-
pebromalar groove may lead to unfavorable con-
tour irregularities. Note that the procedure may
exacerbate the appearance of a wide zygoma in
those with a prominent zygomatic arch.
4.9
Nose
Difficulty
Level:
B,
Effectiveness:
A,
Complications: C
The nose represents the central feature of the
face with an aesthetically profound effect on the
overall balance of other facial components
including the eyes and the mouth. Accordingly,
reshaping a flat and poorly defined nose can add
definition and sophistication to the overall face. It
is not surprising then that surgical rhinoplasty for
enhancing the nose has long been practiced as a
popular procedure in Asians whose nose is gener-
ally flatter and less pronounced than that of
Caucasians. It is for this same reason that filler
rhinoplasty, which allows convenient reshaping
of the nose without the downtime involved in sur-
gery, has become one of the most popular inject-
able filler procedures among Asians [19]. While
the need for repeat treatments due to the dissipa-
tion of the injected HA filler over time may
appear as a drawback against traditional opera-
tive rhinoplasty, this becomes a moot point when
considering the good longevity of HA filler in the
nasal region which may last for up to 5–10 years.
Instead, the countervailing advantages of filler
rhinoplasty are numerous and compelling. Most
significantly, it involves minimum social down-
time since there is almost no bruising or swelling
even immediately after the procedure. Moreover,
in terms of its  safety profile, filler rhinoplasty
does not entail any of the risks arising from sur-
gery such as progression of nasal deviation over
time due to postoperative scar contracture or an
overly pinched and narrow nasal tip. That being
said, HA fillers are not suited for reduction rhino-
plasty, for example, sharpening a bulbous nose,
Summary 1: Injection is performed primar-
ily with a 23-G 5-cm cannula. The cannula
entry point is created at the infratip lobule.
Needles may be used only for performing
deep supraperiosteal placement of HA filler
in the radix. Regarding the choice of HA
filler, use only biphasic HA fillers with
large particles.
Summary 2: The ideal nasal length corre-
sponds to three quarters (3/4) the length of
the lower facial third while the nasal dorsal
width at the radix should approximate the
height of the palpebral fissure or 60% of the
width of the nasal tip. The ideal aesthetic
range for the NLA is between 90° and 110°
and is generally wider in females than in
men.
Summary 3: Dorsum augmentation is indi-
cated for correcting a flat, short nose,
a  nasal hump, saddle nose, or any other
irregularities
in
the
nasal
dorsum.
Nasolabial angle correction is ideal for
treating a low-set, plunged nose, as it gives
anterior projection and cephalic rotation to
a droopy, under projected nasal tip.
Summary 4: Preferably, patients should be
monitored in the office for approximately
30 min postinjection for any ischemic skin
changes such as greyish or violaceous skin
discoloration. Where any vascular occlu-
sion is suspected, subcutaneous injection of
hyaluronidase in sufficient volume (>
3000  U) and high concentration (750  U/
mL) is required along the entire nasal dor-
sum (from nasal tip to radix) where the isch-
emic signs are present.
4  Regional Particulars

161
reducing the size of a large nose, eliminating a
nasal hump, or narrowing a wide nasal dorsum,
etc., since such outcomes can ultimately be
accomplished only by surgical procedures [19].
This chapter aims to provide an overview of the
techniques, useful tips, and precautions involved
in performing nose augmentation with HA filler.
4.9.1
Anthropometry of the Nose
While there is no uniform standard for an ideal
nose that works for every face, an aesthetic nose
may generally be characterized as featuring a
high dorsum and projected tip, though subtle dif-
ferences exist between the sexes, ethnic groups,
and changing aesthetic trends. An ideal nose is
also one that is well proportioned for the indi-
vidual’s face, as facial beauty is a function of the
balanced and harmonious relationship among
various facial components. In this regard, the
metrics for defining ideal facial ratios are by no
means absolute and notions such as the “golden
ratio” does not universally hold true in every
case. Nonetheless, having a general sense of
facial balance and proportionality can be instru-
mental in the planning and treatment of filler rhi-
noplasty in individual patients, as will be detailed
as follows.
The nose is divided into several anatomical
subunits including the dorsum, sidewall, nasal
tip, ala nasi, and columellar (Fig. 4.52). In addi-
tion, there are certain topographic landmarks of
the nose used for cosmetic and reconstructive
procedures as shown in the illustration. Although
the term “nasion” is sometimes used mistakenly
to refer to the deepest point of the nasal root,
technically speaking, the nasion represents the
midpoint of the nasofrontal suture line. Instead,
when referring to the most posterior point of the
Fig. 4.52  Topographical facial landmarks and ideal facial proportions
4.9  Nose

162
nasal bone or the nasofrontal angle, the proper
term should be the “sellion” [19]. However, since
the sellion represents a bony landmark, the more
relevant term for describing the “soft tissue sell-
ion” or the deepest point of the nasal root corre-
sponding to the surface anatomy would be the
“radix.” Meanwhile, the rhinion marks the osseo-
cartilaginous junction, the pronasale represents
the most prominent point of the nasal tip, while
the subnasale refers to the junction between the
columella and the philtrum. The supratip break
represents the starting point of the nasal tip, while
the infratip lobule marks the junction between the
nasal tip and the columella.
On the frontal view, the ideal nasal length is
three quarters the length of the lower facial third,
though it may vary according to the relevant nasal
width. While individuals with a wide nose can
accommodate a slightly increased nasal length,
the same length may appear to be disproportion-
ately long on an individual with a narrow nasal
width. Meanwhile, the ideal nasal width at the
alar base is known to correspond to the intercan-
thal distance, while the actual nasal width is
reported to be slightly longer than the intercan-
thal distance, according to the relevant anthropo-
metric studies. The narrowest segment of the
nasal dorsum is at the radix, where the nasal dor-
sal width approximates the height of the palpe-
bral fissure. The width of the radix is generally
wider in men than in females, but should in no
case exceed 60% of the nasal width at the alar
base even in males. Precaution must be taken, in
this regard, against placing too much volume in
the radix/upper nasal dorsum with the intent of
elevating the nasal height, as the excess volume
would end up spreading sideways broadening the
nasal dorsum as a consequence. Meanwhile, a
gentle curvilinear arch emanating from the
medial brow toward the lateral border of the radix
and extending along nasal dorsum down to the
nasal tip in a straight line creates a natural transi-
tion from the nose to the glabella. Note that any
irregularity or deviation in this line makes the
nose appear asymmetrical or crooked. As a side
note, the nasal tip in Caucasians is more thinly-
skinned and well defined than  that of Asians,
which accounts for the higher prevalence of
bilobed nasal tips in Caucasians [19].
On the lateral view, there are certain key
anthropometric factors that deserve special men-
tion (Table 4.9; Fig. 4.53) [20, 21]. The nasofron-
tal angle (NFrtA) reflects the angle formed by the
glabella-to-radix line intersected by the radix-to-­
tip line. Ideally, this angle should be within
the  115°–130° range. The nasofacial angle
(NFcA) represents the angle formed by a line
extending from the glabella to the pogonion
intersected by the radix-to-nasal tip line and
defines the projection of the nasal tip from the
face. However, individual variations exist in the
fullness of the glabella as well as the location of
the pogonion due to the presence of retrognathia
or prognathia. Further, the glabella-to-pogonion
line is subject to change where the patient were
to  undergo any forehead glabella and/or chin
Table 4.9  Anthropometric factors for filler rhinoplasty
Indication
Anthropometric Factor
Definition
Nasal dorsum
augmentation
Nasofrontal angle
angle between the nasal dorsum line and the glabella line
Modified
nasofacial angle
angle between the nasal dorsum line and the line perpendicular to the
Frankfurt horizontal line (PFHL)
Radix height increment
(RHI%)
Radix height (RH) is the distance between the radix and the line
parallel to the PFHL drawn at the anterior margin of the lower eyelid.
RHI (%) represents the rate of increase (%) in the RH measured
before and after treatment. 
Tip rotation
Nasolabial angle
angle between the line tangent to the columella and the subnasale-to-­
labial limb line
Hump
correction
Rhinion angle
angle between the nasal dorsum line and the rhinion-to-nasal tip line
Reproduced from Ref. [20]
4  Regional Particulars

163
Fig. 4.53 
Anthropometric factors
related to the nose.
MoNFcA modified
nasofacial angel, NFrtA
nasofrontal angle, RA
rhinion angle, NLA
nasolabial angle
augmentation. That being the case, the line per-
pendicular to the Frankfort horizontal line
(PFHL) is more suitable as the reference rather
than the glabella-to-pogonion line for defining
nasal tip projection. The resulting angle formed
by the intersection between the radix-to-tip line
and the PFHL is referred to as the modified NFcA
(MoNFcA) [20]. The aesthetic ideal for MoNFcA
is 35°–40°. Meanwhile, the nasolabial angle
(NLA), useful for assessing the effectiveness of
nasal tip rotation, represents the angle formed by
the line tangent to the columella intersected by
the subnasale-to-labial limb line [19]. Opening
the nasolabial angle beyond 90° can create a
more refined and sophisticated nasal contour on
the profile view. The ideal aesthetic range for the
NLA is between 90° and 110°, though it may dif-
fer by ethnicity and sex, with the female NLA
being wider than that of males. The ideal NLA of
males is reported to be less than 90°.
To date, the efficacy of nasal radix/dorsum
augmentation via surgery or filler rhinoplasty
could only be inferred indirectly by reference to
the changes in the nasofrontal or nasofacial
angles. A direct comparison of the nasal dorsal
height pre- and posttreatment was hard to make
due to the lack of prior literature providing
objective anthropometric assessments. It was
against this backdrop that the author developed
an indicator for objectively establishing the
incremental increase in nasal dorsal height post-
treatment via anthropometric measurement,
termed as the Radix Height Increment (RHI)
[20]. The RHI represents the rate of increase
4.9  Nose

164
(%) in the distance between the radix and the
line parallel to the PFHL drawn at the anterior
margin of the lower eyelid measured before and
after treatment. In addition, the author also
developed the concept of the rhinion angle
(RA), defined as the angle between the radix-to-
rhinion line intersected by the rhinion-to-nasal
tip line to ensure an objective anthropometric
assessment of nasal hump correction. The RA is
0  in those with no nasal humps and becomes
higher with increased severity.
In the anthropometric study of 242 patients
who received HA filler rhinoplasty at the author’s
clinic, the NFrtA was found to have increased on
average by 5.7° from 138.7°  ±  6.1° to
144.4° ± 4.9°, the MoNFcA to have decreased on
average by 1.9° from 30.2° ± 4.6° to 28.3° ± 4.1°,
while the NLA showed a 9.4° increase from
87.4° ± 10° to 96.8° ± 10° [20] (Table 4.10). In
patients who received nasal dorsum augmenta-
tion at the author’s clinic, the RHI was found to
have increased on average by 78.3% postinjec-
tion. In 25 patients who received HA filler for
hump correction, the RA showed a decrease of 8°
from 11° to 3° [20].
4.9.2
Ethnic Differences
The typical features of a leptorrhine (tall and
thin) Caucasian nose have been described above.
By comparison, the platyrrhine (broad and flat)
African nose is characterized by a low radix,
short concave dorsum, widened alae base, a bul-
bous and under projected tip, flared alae with
round nostrils, and extremely thick skin. The
mesorrhine (intermediate) Asian nose is charac-
terized as a blend of the two; it is typically char-
acterized by a low broad dorsum, short nasal
bone, a round under projected and under-rotated
tip, columellar recession, somewhat rounded
nostrils, and moderately thick skin [19]. The
nasal tip is unilobular rather than sharp and well
defined. Note, however, that even within the
Asian population, stark distinctions are found
among different facial morphotypes [18].
Specifically, the northern facial type common
among those from Mongolia, Korea, and
Northern China, etc. manifest a high nasal dor-
sum with small narrow nasal ala; the southern
facial type typical of those from The Philippines,
Thailand, Vietnam, and other Southeast Asian
Table 4.10  Comparison of anthropometric factors pre- and postfiller rhinoplasty
Subgroup
Anthropometric factors
(°)
Preinjection
Postinjection
Difference
Nasal dorsum
augmentation
NFrtA
138.0 ± 6.2
144.7 ± 4.5
6.7 ± 4.3**
MoNFcA
30.8 ± 4.9
28.3 ± 4.1
−2.5 ± 2.8**
RHI
100%
186%
86%
Tip rotation
NLA
80.0 ± 12.3
91.3 ± 9.3
11.3 ± 5.1**
Whole nose
augmentation
NFrtA
139 ± 6.1
144.2 ± 5.1
5.2 ± 3.7**
MoNFcA
29.7 ± 4.3
28.1 ± 4.0
−1.6 ± 2.8**
NLA
87.6 ± 9.6
96.9 ± 10
9.3 ± 4.5**
RHI
100%
176.2%
76.2%
Hump Correction
RAc
10.9 ± 2.7
3.3 ± 2.9
−7.6 ± 2.6**
Total
NFrtAa
138.7 ± 6.1
144.4 ± 4.9
5.7 ± 4.1**
MoNFcAa
30.2 ± 4.6
28.3 ± 4.1
−1.9 ± 2.9**
NLAb
87.4 ± 10
96.8 ± 10
9.4 ± 4.5**
RHIa
100%
178.3%
78.3%
aMeasured only among the nasal dorsum augmentation group and whole nose augmentation group (234 among 242)
bMeasured only in the tip rotation group and the whole nose augmentation group (130 among 242)
cMeasured only in the hump correction group. (25 among 242)
NFrtA nasofrontal angle, MoNFcA modified nasofacial angle, RHI radix height increment, NLA nasolabial angle, RA
rhinion angle
**p < 0.01
Reproduced from Ref. [20]
4  Regional Particulars

165
countries exhibit a flat nasal dorsum with wide,
round nasal ala, while the intermediate facial
type representative of those from Hong Kong,
Taiwan, Southern China represent a combination
of the other two. As such, applying a strict ethnic
classification becomes increasingly less mean-
ingful, as differences arise even within the same
ethnic population, distinct ethnic features become
more muted due to increased interracial mar-
riages, and standards of beauty become increas-
ingly universal. That notwithstanding, a general
appreciation of such ethnic differences can lend
some precious insight when providing filler rhi-
noplasty to ethnic patients.
4.9.3
Anatomical Considerations
The soft tissue of the nose consists of the follow-
ing five layers from the outer to the deep: skin—
subdermal fatty layer—fibromuscular layer
including the procerus m. and nasalis m.—deep
fatty layers—and periosteum/perichondrium lay-
ers [21]. The upper nasal dorsum is covered by
the smooth, pliable, and mobile soft tissue enve-
lope which allows sufficient space for HA filler
placement both above and below the fibromuscu-
lar layer, that is, at the subdermal fat and the mus-
cular/deep fatty layers. In contrast, the tight
connection between the dermis and the fibromus-
cular layer at the nasal tip restricts the placement
of HA filler in the subdermal fatty layer and
requires most of the volume to be deposited
instead in the deep fatty layer (Fig. 4.54). The use
of a needle is best avoided during filler rhino-
plasty, as the vascular supply in the nasal area
runs extensively throughout the fibromuscular
layer as well as the fatty layers lying both super-
ficial and deep to it. That said, needles may be
used for injecting HA filler deep into the supra-
Fig. 4.54  Cross section of nose (courtesy of Pf. Kim Hee-Jin)
4.9  Nose

166
periosteal layer of the radix (located at the upper
nasal dorsum) where the vasculature runs
­superficially between the fibromuscular and the
subdermal fatty layer.
The blood supply to the external nose is pro-
vided largely by the ophthalmic artery, a branch
of the internal carotid system, and the facial
artery, a branch of the external carotid system.
The upper nasal dorsum is principally sup-
plied by the dorsal nasal artery, a branch of the
ophthalmic artery and the angular artery branch-
ing out from facial artery (Fig. 4.17). The blood
supply to the lower nasal dorsum including the
nasal tip originates primarily from the lateral
nasal artery, while the columellar is supplied by
the columellar branch of the superior labial artery
and the inferior alar branch of the facial artery
(Fig. 4.17) [21]. These arteries form broad-based
anastomosis among themselves at the nasal dor-
sum. Therefore, any inadvertent intravascular
injection of HA filler at the nasal tip is capable of
causing skin necrosis across the entire nasal dor-
sum or, worse still, traveling through the dorsal
nasal artery into the ophthalmic artery, leading to
blindness as consequence.
4.9.4
Pretreatment Assessment
Perform an objective assessment of the nasal
shape and size, before consulting with the patient
on what they subjectively consider to be an aes-
thetic and balanced nose. First, evaluate the nose
from the frontal view on the basis of the nasal
dorsal length and height, nasal dorsal width,
width of the nasal bone, width and size of the ala
nasi, size and shape of the nasal tip, extent of
columella show, nostril shape, and extent of nos-
No treatment
or D.A at radix only
N.A.C +
D.A between rhinion
and supratip break
+ T.C
N.A.C +
D.A between rhinion
and supratip break
N.A.C + D.A
N.A.C + D.A
+T.C
D.A at radix only
No
Yes
Yes
No
Yes
Yes
No
No
Yes
Yes
No
Inadequate tip projection,
Tip rotation?
Inadequate tip projection,
Tip rotation?
Long nose?
Hump
Bulbouse nose?
Bulbouse nose?
a
b
Low set nasal dorsum
Shot nose
No
Yes
D.A
No treatment
N.A.C
D.A + N.A.C
+ T.C
D.A + N.A.C
N.A.C + T.C
No
No
No
No
Yes
No
No
Yes
No
Yes
Yes
Yes
D.A + N.A.C
+ C.P
N.A.C + C.P
+ T.C
Recessed
columella
Recessed
columella
Bulbouse
nose
Inadequate Tip
projection
Inadequate Tip
projection
Bulbouse
nose
Fig. 4.55  Flow chart of pretreatment assessment for nose filler. (a) General assessment, (b) hump assessment (*N.A.C.
nasolabial angle correction, *T.C. tip correction, *D.A. dorsum augmentation, *C.P. columella plasty)
4  Regional Particulars

167
tril show. Consideration must also be given to the
adequacy of the nasal length relative to the length
of the face, forehead, and the lower facial third.
Consider also whether the nasal length is in ade-
quate proportion to the nasal width; and also
whether the width of the nasal dorsum is in ade-
quate balance with the width of the ala base. The
nasal tip should be also appraised for the pres-
ence of any bifid, bulbous, or plunging tip or
inadequate tip projection.
Next, from the profile view, establish the pres-
ence or absence of dorsal humps or depressions
lying between the rhinion and the nasal tip. Also,
assess the nose for the adequacy of nasal dorsal
height, nasal tip rotation, tip projection, colu-
mella length and columella show. The activity of
the depressor septi nasi m. during speaking or
smiling is also more visible from the lateral view.
Gender-specific differences as well as the eth-
nicity of the patient must also be reflected in the
treatment plan. For an Asian patient, it should be
further determined whether the patient belongs to
the northern, southern or intermediate facial mor-
photype. Respecting different ethnic aesthetic
preferences can be relevant, for example, when
shaping the nasal tip with HA filler. While Asians
tend to feature a nasal tip relatively larger and
more rounded than that of Caucasians, and thus
favor augmenting a bifid or overly sharp nose tip
to bring it into better conformity with the prevail-
ing aesthetic norm, a Caucasian patient may pre-
fer instead to retain his/her bifid nasal tip.
Meanwhile, skin in Asians tends to be generally
thicker, thus allowing for an easier injection than
in Caucasians. On the other hand, when treating
an Asian patient, keen attention should be paid to
the patients’ past medical history, in particular,
for any reference to a previous nose surgery, a
procedure popular among Asians. Filler rhino-
plasty should be avoided in areas where a nasal
implant is placed; great caution is required even
where the implant had been subsequently
removed  as it heightens  the risk of  vascular
complications.
It is also imperative to confirm with the
patient beforehand what they deem as the ideal
nasal dorsal height. In most cases, however,
patients tend to lack a clear idea of the desired
dorsal height as they typically undergo the pro-
cedure for the very first time. For ease of com-
munication, therefore, the  author  customarily
presents the patient with the following three
options; (a) maximal enhancement of the nasal
dorsum as long as results appear natural in the
eyes of a stranger, (b) subtle enhancement of the
nasal dorsum perceptible only to the patient her-
self, or (c) somewhere in between. The patient’s
subjective preferences are also important in
defining the ideal nasal width. Note that an aes-
thetic male nose can be wider than that of a
female. Meanwhile, when performing a nasola-
bial angle correction with HA, it is advisable to
identify and disclose to the patient prior to treat-
ment any nostril show they may present, and
inquire whether the patient would be comfort-
able with a slightly greater increase in nostril
show following the procedure. Also, patients
who have a wide nasal dorsum largely attribut-
able to the width of the underlying nasal bone
should be forewarned that nasal dorsum aug-
mentation with HA filler may serve to further
expand their nasal width.
4.9.4.1 Pretreatment Assessment
Flowchart (Fig. 4.55)
As the first step, determine whether the patient
has a low-set nasal dorsum or a short nose. Next,
evaluate the nose for the adequacy of nasal tip
rotation and projection. Patients presenting a low
nasal dorsum with a short nasal length require
nasal dorsum augmentation, while patients with
an underprojected or underrotated nasal tip are
candidates for columella and nasolabial angle
correction. Nasal tip correction (i.e., augmenta-
tion of the nasal tip) may or maynot be indicated
depending on the bulbousity of the nasal tip. The
decision whether to create the arch-shaped transi-
tion between the glabella and the dorsum can be
deferred until during the treatment of nasal dor-
sum. When treating a humped nose, consider-
ation must first be given to the length of the nose
relative to the overall facial length. Where the
nasal length is disproportionately long for the
face, nasal hump correction should be confined to
the lower portion of the nose (i.e., between the
rhinion and the nasal tip) combined with nasola-
bial angle correction. Corresponding augmenta-
tion in the upper dorsum (i.e., the radix) is best
avoided in such patients, as it can make the nose
appear even longer.
4.9  Nose

168
4.9.5
Injection Technique
(Table 4.11)
Filler rhinoplasty can be broadly divided into five
subcategories based on the injection site, namely
nasal dorsum augmentation, glabella correction,
nasal tip correction, columella correction, and
nasolabial angle correction (Fig. 4.56). Dorsum
augmentation is indicated for patients with a flat
or short nose, a nasal hump, saddle nose or any
other irregularities in the nasal dorsum, and is
performed by injecting HA filler from the radix to
the supratip break along the nasal dorsum.
Glabella correction is often undertaken in
­conjunction with nasal dorsum augmentation to
create a confluent arch-shaped transition extend-
ing from the medial brow of the glabella region to
the nasal dorsum. Nasal tip correction is suitable
for patients with bifid or otherwise blunt nasal tip,
in which small volumes of HA filler are directly
injected to augment the weak nasal tip, and inci-
dentally allow mild cephalic rotation and slight
projection. For columella correction, HA filler is
injected in the columella to project the recessed
columella; the procedure is often performed in
conjuction with nasolabial angle correction.
Nasolabial angle correction is performed by
injecting HA filler deep into the anterior nasal
spine of the subnasale. This helps to increase the
nasolabial angle to more than 90°, causing not
only nasal tip projection but also cephalic rotation
of the nasal tip. As previously mentioned, nasola-
bial angle correction is routinely performed in
tandem with columella correction, the combined
effect of which is equivalent to a columellar strut
insertion in surgical rhinoplasty. The procedure is
ideal for patients with a plunged or pulling nose,
as it projects the low and droopy nasal tip away
from the face as well as rotating the tip upwards
in a superior direction. Injection of HA in the
anterior nasal spine also helps to narrow the nasal
base on the frontal view while visually shortening
a long nasal dorsum by tilting the nasal tip
upwards. Further, an obtuse nasolabial angle
wider than 90° combined with a slight protrusion
of the columella contributes to a more sophisti-
cated nasal contour on the profile view.
Use only biphasic HA fillers with large parti-
cle size for injecting the nose. Note that HA filler
has a propensity to attract water from surround-
ing tissues and the overlygin skin of the nasal
dorsum is thin. To prevent lateral expansion of
the nasal dorsum due to the undesired swelling of
the HA filler, the use of biphasic HA filler, which
is less hydrophilic in nature, is preferred over
monophasic  type HA filler. Also, in situations
where the use of a needle is inevitable, biphasic
HA fillers better lend themselves to preinjection
blood aspiration tests. Meanwhile, in order to
avoid inadvertent intravascular injection of HA
filler, the use of the cannula is recommended
instead of a needle. The practitioner may use a
combination of different cannula sizes from
among the 23-G 5-cm, 25-G 5-cm, and 27-G
3-cm as appropriate, depending on the relevant
injection site and indication.
The cannula entry point is created at the
infratip lobule located below the pronasale. The
desired depth of injection is the deep fatty layer or
supraperiosteal layer. Where necessary, addi-
tional injection in the subdermal superficial fatty
layer may be performed subsequent to the pri-
mary augmentation in the supraperiosteal layer.
In case where the use of a needle is inevitable, a
27-G or 30-G needle may be used for the injec-
tion. In such case, aspiration should be performed
prior to each injection to ensure that the needle is
Table 4.11  Summary of Injection Technique for nose
augmentation
Item
Contents
Needle vs. Cannula
23-G 5-cm cannula
HA filler
Biphasic HA filer with large
particle size
Amount of HA filler
0.5–2 mL
Depth of injection
Deep subcutaneous layer
above the periosteum.
Entry point for
cannula 
Infratip lobule
Target area
nasal dorsum augmentation,
glabella correction, nasal tip
correction, columella
correction, and nasolabial
angle correction
Anesthetics
Epi-lidocaine local
anesthetics at entry point
Nondominant hand
 Pinch the dorsum of nose to
prevent lateral migration of
HA filler during dorsum
augmentation 
4  Regional Particulars

169
not accidentally placed in the vessel. Note, how-
ever, that a negative aspiration does not necessar-
ily guarantee 100% safety, as finer needles with
smaller inner diameter may not adequately draw
reflux blood even when  it has entered a blood
vessel [22]. According to one study, needles
sized 27G or thinner were shown to be not ame-
nable to aspiration [22].
As a general preventative strategy against
intravascular injection, therefore, it is best to
avoid the use of a needle altogether in the region
between the nasal tip and the rhinion, as the vas-
culature in this area traverses even in  the
deep subcutaneous fat layer and muscular layers.
Not coincidentally, in the five incidences involv-
ing intravascular injections encountered in the
author’s practice, a 30-G needle was used at the
nasal tip. By comparison, the radix is a relatively
safer area to inject as the blood supply runs
mostly superficial to the musculature and thus
Fig. 4.56  Filler
rhinoplasty can be
broadly divided into five
subcategories based on
the injection site,
namely nasal dorsum
augmentation, glabella
correction, nasal tip
correction, columella
correction, and
nasolabial angle
correction
4.9  Nose

170
intravascular injections can be avoided by inject-
ing deep to the muscle at the supraperiosteal
layer (Fig. 4.54).
With respect to anesthesia, prior injection of
dental lidocaine with epinephrine in the cannula
entry point is advised to help reduce pain and
bleeding during the procedure. Wait for 3–5 min
for the onset of dermal blanching triggered by
epinephrine to create the needle entry point with
a 21-G needle. When injecting HA filler using a
30-G needle, an anesthetic numbing cream
applied 20–30 min in advance can help reduce
discomfort during the procedure.
The adequate volume of HA filler to be
injected varies widely depending on the indica-
tion and extent of correction required by each
patient. In the anthropometric study involving
242 patients who underwent nose augmentation
with HA filler at the author’s clinic, the injected
volume range was 1 ± 0.4 mL for nasal dorsum
augmentation, 0.9 ± 0.3 mL for nasolabial angle
correction, and 1.6 ± 0.5 mL for whole nose aug-
mentation [20]. Broken down by specific subsites
of injection, the range of volume injected was
0.3 ± 0.2 mL for the glabella area, 0.8 ± 0.4 mL
for the nasal dorsum, 0.4 ± 0.2 mL for the nasal
tip, and 0.7 ± 0.3 mL for the columella and sub-
nasale, respectively.
4.9.6
Nasal Dorsum Augmentation
(Fig. 4.57)
The cannula is inserted into the entry point cre-
ated at the nasal tip and pushed all the way up to
the radix, along the midline of the dorsum
(Fig. 4.58). The HA filler is injected in a retro-
grade manner from the radix to the supratip
breakpoint to build a “column” of injected HA
filler to elevate the nasal dorsum to the desired
height (Fig.  4.59). Subsequent HA filler injec-
tions are made on either side of the column to the
desired width using the same technique, so that
the transition to the nasal side wall is natural. Any
unwanted contour irregularities between the
heightened nasal dorsum (i.e., the injected HA
filler column(s)) and the nasal side wall can be
smoothened out with detailed corrections using a
30-G cannula from the nasal sidewalls. Note that
the width of the nasal dorsum should be the nar-
rowest at the radix, approximating 60–70% of the
width of the nasal tip in an ideally proportioned
nose. While the radix in an Asian face typically
sits on the inter canthal line connecting the medial
canthus of both eyes, injection of HA filler should
relocate the radix 3–5 mm superior to its original
position. Consequently, the repositioned radix
should sit on a horizontal line connecting the
highest points of the left and right eye lash-line or
supratarsal crease. While HA filler may be
injected as far down as the nasal tip in case con-
current nasal tip augmentation is required; other-
wise it is placed only down to the supratip break.
Generally speaking, HA filler injection in the
rhinion is best avoided if not limited to the mini-
mum extent, considering the slight anterior pro-
trusion naturally present at the osseocartilaginous
junction as well as its very thin skin envelope.
For the purpose of enhancing the nasal dorsal
height, most of the volume should be placed
instead at the radix located superior to the rhin-
ion, while injection of the area inferior to the
rhinion should proceed no further than the point
immediately above the nasal tip, limited only to
the extent of smoothening the transition to the
elevated upper dorsum. The thumb and index
finger of the nondominant hand should be used
to pinch the upper nasal dorsum at the intercan-
thal line to prevent lateral migration of HA filler.
Unwanted irregularities in contour should be
massaged away via postinjection molding.
4.9.7
Glabella Correction
To ensure a smooth transition from the reshaped
upper nasal dorsum to the orbital rim, arches nat-
urally extending from the medial eyebrows
toward the radix of the augmented nasal dorsum
are created by injecting HA fillers into the
glabella-­to-radix region using a 27-G cannula
(Fig. 4.60). Incidentally, heightening of the upper
nasal dorsum may cause an obvious “step” at the
junction where the elevated radix meets the rela-
tively low-lying central glabella. Accordingly, the
depression in the center of the glabella should be
4  Regional Particulars

171
a
c
b
Fig. 4.57  (a) Before and (b) after nasal dorsum augmentation (c) Superimposed image of nasal dorsum before and
after augmentation clearly domonstrates the heightened dorsum of nose
4.9  Nose

172
Fig. 4.59  Depth of
injection for nasal
dorsum augmentation
Fig. 4.58  The cannula entry point for nasal dorsum augmentation
4  Regional Particulars

173
filled in so as to remove such irregularity and to
ensure an appropriate nasofrontal angle when
viewed from the side. Note, however, that over-
filling the arch connecting the glabella to the
radix can widen the nasal dorsum, giving rise to
the appearance of the “Avatar nose” or a “lion
nose.” Hence, care must be taken to ensure that
the thickness of radix does not exceed 60% of the
total width of the nose measured at the nasal base.
The same approach may be employed on a
patient with a previous augmentation rhinoplasty
to address any demarcations  or “step” present
between the inserted silicone implant and the
glabella.
4.9.8
Nasal Tip Correction
A weak and overly pointy nasal tip can be cor-
rected by placing HA filler into the interdomal
area. It must be pointed out, however, that the
size of the augmented tip should not be bigger
than that of the ala nasi, since an excessively
prominent nasal tip would be just as undesirable
from an aesthetic perspective. HA filler injection
into the interdomal area can also be beneficial
for patients with a bifid nasal tip, as it smoothens
the visible indentations in the nasal tip.
Conversely, nasal tip augmentation is not advised
for patients with a large round nasal tip, since
they would end up instead with a prominently
bulbous nose.
In principle, filler rhinoplasty is not indicated
for sharpening a bulbous nasal tip. That said, HA
filler placed in discrete amounts (0.1–0.2  mL)
subdermally at the pronasale with a 27-G cannula
or intradermally using the 30-G needle can add
subtle projection to the pronasale, effecting a
slightly sharper, better defined nasal tip
(Fig. 4.61). This also has the effect of improving
nasal tip projection and rotation from the lateral
view. Of course, it bears reminding that where
Fig. 4.60  The cannula entry point for glabella correction
4.9  Nose

174
a
b
Fig. 4.61  (a) The cannula entry point for nasal tip correction. (b) Depth of injection for nasal tip correction
4  Regional Particulars

175
nasal tip rotation is the primary goal, concurrent
corrections should preferentially be made to the
columella and the nasolabial angle rather directly
to the nasal tip itself.
4.9.9
Columella Correction
Too little columella show when observed in the
lateral view is undesirable; instead, a slight pro-
trusion of the columella creates a much more
refined and sophisticated appearance. To this
end, subcutaneous injection of HA filler in vol-
ume ranging from 0.2 to 0.5 mL into the colu-
mella helps to project the retracted columella
(Fig. 4.62).
4.9.10 Nasolabial Angle Correction
The nasolabial angle is known to range between
95° and 120° in Caucasians, while the corre-
sponding angle in Asians often falls below 90°.
Injecting 0.3–1 mL of HA filler in the subcuta-
neous layer of the subnasale (i.e., on the nasal
spine side) (Fig.  4.63) opens the nasolabial
angle to beyond 90°, creating cephalic rotation
of the nasal tip (Fig. 4.64). Enhancing the naso-
labial angle not only refines the nasal contour on
the profile view by everting the nasal tip and
improving tip projection, but also has the effect
of visually shortening a long nasal dorsum on
frontal view. As the procedure is regularly per-
formed in conjunction with columella correc-
Fig. 4.62  Depth of
injection for columella
plasty
4.9  Nose

176
tion with HA, the net effect is equivalent to a
columellar strut graft in surgical rhinoplasty.
Apart from increasing the nasolabial angle on
profile view, injection of HA around the anterior
nasal spine also helps to narrow the nasal base
on the frontal view, by tenting the soft tissue
layers of the nasal base superiorly in much the
same way tent poles are used to prop up a tent;
that is, the taller the poles, the narrower the
space inside the tent. Incidentally, lifting  the
nasal tip via nasolabial angle correction may
create a saddle between the rotated nasal tip and
the rhinion, which must be filled concurrently
with HA filler to straighten the nasal profile. It
must also be noted that HA filler injected in
excess volumes in the subnasale may add
unwanted bulk to the upper portion of the phil-
trum. The procedure is also advised against
Fig. 4.63  Depth of
injection for nasolabial
angle augmentation
4  Regional Particulars

177
patients with upturned nostrils or over rotated
nose, as it can cause excessive nostril show. The
thumb and index finger of the nondominant
hand should be used to pinch the nasal tip to
prevent any superior migration of HA filler from
causing unwanted bulbosity at the nasal tip.
4.9.11 Injection Techniques
for Special Indications
4.9.11.1
Humped Nose (Fig. 4.65)
A mild nasal hump is easily corrected by injecting
HA filler only in the upper nasal dorsum near the
radix (i.e., the area just above the hump). However,
in the case of a severe hump, concurrent HA filler
injection into the nasolabial junction and the colu-
mella is required. This is because correcting the
radix only without the corresponding elevation of
the nasal tip can cause the nasofrontal angle to
detract beyond the natural range of 140°, and visu-
ally elongate the nasal dorsum. For partial correc-
tion of the upper nasal dorsum only (i.e., around the
radix), a 30-G needle may be used instead of a can-
nula. Deep injections in the supraperiosteal layer
must be performed when injecting with a needle.
4.9.11.2
Wide Nasal Base (Fig. 4.66)
Concurrent use of HA filler in the columella and
the nasolabial angle can help to narrow the nasal
a
b
Fig. 4.64  (a) Before and (b) after nasolabial angle augmentation
4.9  Nose

178
base by increasing the projection and upward
rotation of the nasal tip. Further, elongating the
nose via nasal dorsum augmentation can also
give the visual illusion of a slimmer nose. In this
regard, it may be worthwhile to maximize the
length of the radix during nasal dorsum aug-
mentation so that the ratio between the length of
the nose and the width exceeds the range of
1:1.4–1.5.
4.9.11.3
Bulbous Nose
As a general rule, filler rhinoplasty is not indi-
cated for sharpening a bulbous nose prevalent
among Asians. However, injecting very small
amounts of HA filler intradermally in the prona-
sale using a 30-G needle may be attempted to
effect subtle definition and sharpness to the nasal
tip. Also, a visual illusion of a narrower nose can
be effected by increasing the length of the nose
with nasal dorsum augmentation.
4.9.11.4
Pulling Nose (Arrow nose)
(Fig. 4.67)
Priority should be placed on enhancing the
nasolabial
angle
and
the
columella.
Augmentation of the nasal dorsum may or may
not be performed depending on the individual
case. Notably, nasal dorsum augmentation is
not recommended for patients with a long
dorsum.
a
b
Fig. 4.65  (a) Before and (b) after correction of humped nose. (Dorsum augmentation combined with nasolabial angle
augmentation)
4  Regional Particulars

179
4.9.11.5
Deviated Nose
Curved Nose
The nasal profile can be straightened by filling the
concavity present in the mid portion of the nose and
filling the contralateral depressions at the radix and
the nasal tip. Precaution should be taken against cre-
ating an overly thick radix or dorsum (Fig. 4.68).
Slanted Nose (Deviated Septum)
HA filler should be injected into the contralateral
side of the deviated septum at the supratip break
point behind the nasal tip and ipsilateral side at
the radix (Fig. 4.69).
a
b
c
d
Fig. 4.66  (a, c) Before and (b, d) after correction of Wide Nasal Base. (Dorsum augmentation combined with nasola-
bial angle augmentation)
4.9  Nose

180
a
b
c
d
Fig. 4.67  (a, c) Before and (b, d) after correction of pulling nose (arrow nose)
4.9.12 Combination Treatment
Additional HA filler injection into the glabella
may be necessary in patients with deep glabellar
grooves. Patients demonstrating pronounced
activity of the depressor septi nasi m. may
require adjunct injection of BoNT-A (4 U) in the
subnasale to prevent the downward pull and
drooping of the nasal tip during speaking or
smiling [23].
4  Regional Particulars

181
Fig. 4.68  Injection technique for the correction of curved nose
Fig. 4.69  Injection technique for the correction of slanted nose
4.9  Nose

182
4.9.13 Complications
There may be mild transient complications fol-
lowing HA filler injection in the nose including
temporary swelling and erythema, bruising,
headache, as well as rare incidences of infec-
tion. On occasion, erythema may persist for
several months in peripheral regions such as
the nasal tip. This is presumed to arise from the
capillary dilatation triggered as a secondary
reaction to compensate for the impaired blood
circulation from  the vascular compression
caused by the HA filler injection into the dense
and tight tissue of the nasal tip. Symptoms
continuing beyond several weeks should be
reversed
by
injection
of
hyaluronidase.
However, the most serious adverse event fol-
lowing nose augmentation with HA filler is
vascular complication. The causes of vascular
compromise are largely two-fold, that is, vas-
cular compression from the pressure exerted
by injected filler material and the intravascular
embolization from inadvertent intravascular
injection of fillers. Extreme care must be taken
to avoid intravascular injection of HA filler
which, though rare, may bring about skin
necrosis and even blindness in the most disas-
trous case. Ischemic color changes such as
immediate postinjection blanching or viola-
ceous or grayish skin discoloration (Fig. 4.70)
occurring 20–30 min after HA filler injection
should be considered as a sign of vascular
embolization, for which timely and adequate
treatment must be administered (Fig. 4.70). If
left unaddressed, multiple reticular erythema-
tous patches may develop the next day across
the nasal dorsum, glabella and forehead
(Fig. 4.71), accompanied by multiple pustules
in severe cases (Fig. 4.72). In the extreme, the
pustules may progress to skin necrosis with
crust formation (Fig. 4.73a).
Practitioners should also be vigilant of the risk
of blindness following HA filler injection in the
nasal region. According to the literature review
by Beleznay et al., the nose was the second most
common site for filler induced blindness repre-
senting 25.5% of all cases after the glabella
(38.8%).
Notably, HA filler injected under strong pres-
sure into the dorsal nasal artery may migrate in
reverse direction to the proximal ophthalmic
artery and occlude the distal branches of the
ophthalmic artery such as the retinal artery and
the posterior ciliary artery, leading to blindness
(see Sect. 5.1.4). While the blood supply to the
upper nasal dorsum is mainly provided by the
dorsal nasal artery and the angular artery, the
lower part of the nose receives blood supply pri-
marily from the lateral nasal artery, whereas the
nasal tip is supplied by the the columellar branch
of the superior labial artery and the inferior alar
branch of the facial artery. The dorsal nasal
artery communicates extensively with these
arterial branches at the nasal dorsum. Therefore,
any inadvertent injection of HA filler at the nasal
tip or even at the columella may travel retro-
grade through the dorsal nasal artery into the
ophthalmic artery via the broad-based anasto-
mosis at the nasal dorsum and contribute to
blindness as well.
Vascular complications are more likely to occur
in patients whose vascular circulation has already
been compromised due to a previous nose surgery,
or whose blood vessels are adhered to the scar tis-
sue in the operated area. Note that vessels trapped
inside scar tissue adhesions become easy targets
for needle penetration during filler rhinoplasty,
and are substantially more vulnerable to the risk of
intravascular filler injection. Hence, particular care
must be taken when treating a patient with history
of a nose surgery even if the nasal implant had
been subsequently removed.
The cannula technique is generally recom-
mended when injecting the nose to minimize the risk
of vascular occlusion. That said, precaution is still
required even when injecting with a cannula as
small-diameter cannulas remain capable of piercing
through a vessel. As a general rule, the use of can-
nulas sized 25 or larger, gentle movement, and slow
injection speed help reduce the risk of intravascular
filler injection. In case the use of a needle is inevita-
ble, needles should be used only for delivering HA
4  Regional Particulars

183
Fig. 4.70  Ischemic color changes such as immediate
postinjection blanching or violaceous or greyish skin dis-
coloration occurring 20–30 min after nose filler injection
should be considered as a sign of vascular embolization.
(Photo: courtesy of Dr. Kim Sang-Yon)
Fig. 4.71  Multiple reticular erythematous patches may develop across the nasal dorsum, glabella and forehead the next
day after nose filler injection. (Photo: courtesy of Dr. Kim Sang-Yon)
4.9  Nose

184
supraperiosteally in the radix where the vasculature
runs superficially close to the skin surface. Aspiration
should be performed prior to each injection in such
case to ensure that the needle was not accidentally
placed in a blood vessel. Note however, that the
results of blood aspiration tests are not fail proof, as
the test may produce false negatives, especially
where the injection was performed using gel-type
HA fillers or small diameter needles. In the five
cases of vascular occlusions from filler rhinoplasty
encountered by the author, HA fillers were injected
at the nasal tip with a needle instead of a cannula.
Not coincidentally, gel-type HA fillers (newly
released at the time) had been injected in five cases.
In three cases out of five, the event went unnoticed
during the treatment, and it was not until the next day
that mottled erythematic patches began appearing on
the patient’s face, which took approximately
1  month to fully disappear. Fortunately, all three
patients recovered without experiencing any severe
sequelae such as pustule formation or skin necrosis.
Since then, the author has made it a rule to use
only cannulas and particulate-type biphasic HA
filler in the nose. It is also the policy of the clinic
to have the patient remaining in the office for
30  min after injection of  nose filler to ensure
prompt detection of any ischemic skin changes,
and to advise the patient to revert back to the
clinic immediately upon noticing any violaceous
changes in the skin 1–2 hrs of their departure.
While it may prove elusive to pinpoint the exact
location of the arterial occlusion in which to inject
hyaluronidase, hyaluronidase is known to diffuse
across the arterial wall to reach the hyaluronic acid
held in the blood vessel when infiltrated in large
volumes [23]. Hence, subcutaneous injection of
Fig. 4.72  Multiple pustules may develop in severe cases. (Photo: courtesy of Dr. Kim Sang-Yon)
4  Regional Particulars